Avascular necrosis (AVN) of the talus can be a cause of significant disability and is a difficult problem to treat. The most common cause is a fracture of the talus. We have done a systematic review of the literature with the following aims: (1) identify and summarize the available evidence in literature for the treatment of talar AVN, (2) define the usefulness of radiological Hawkins sign and magnetic resonance imaging in early diagnosis, and (3) provide patient management guidelines. We searched MEDLINE and PUBMED using keywords and MESH terminology. The articles' abstracts were read by two of the authors. Forty-one studies met the inclusion criteria of the 335 abstracts screened. The interventions of interest included hindfoot fusion, conservative measures, bone grafting, vascularized bone graft, core decompression, and talar replacement. All studies were of Level IV evidence. We looked to identify the study quality, imprecise and sparse data, reporting bias, and the quality of evidence. Based on the analysis of available literature, we make certain recommendations for managing patients of AVN talus depending on identified disease factors such as early or late presentation, extent of bone involvement, bone collapse, and presence or absence of arthritis. Early talar AVN seems best treated with protected weight bearing and possibly in combination with extracorporeal shock wave therapy. If that fails, core decompression can be considered. Arthrodesis should be saved as a salvage procedure in late cases with arthritis and collapse, and a tibiotalocalcaneal fusion with bone grafting may be needed in cases of significant bone loss. Role of vascularized bone grafting is still not defined clearly and needs further investigation. Future prospective, randomized studies are necessary to guide the conservative and surgical management of talar AVN.

Background: The role of arthrodesis as a salvage procedure in Diabetic Charcot Neuroarthropathic deformities of the Foot and Ankle is controversial due to relatively high complication rates reported in literature. We intend to present our experience with a retrospective analysis of Ankle and Hindfoot arthrodesis in deformities due to Diabetic Charcot Neuroarthropathy. Study design: A retrospective observational analysis of selected Diabetic Neuropathic Ankle and Hindfoot cases operated at a single centre. Patients and methods: In a study duration extending 7.5 years, 46 operated sites in 44 patients were included in the study. These patients were treated by one of the following procedures: Tibiotalocalcaneal arthrodesis, Pantalar arthrodesis, Ankle arthrodesis, Triple arthrodesis and isolated subtalar arthrodesis. The results were analysed with regard to wound healing and its complications, clinical and radiological progress of union and non-union rates and deformity correction (i.e. whether a plantigrade foot could be achieved and a standard foot wear could be worn post correction). Results: There were four superficial and two deep infections (13%). Symptomatic radiological non-union at one or more joints was seen in 12 cases (26%). Thirty cases united primarily (65%) and showed radiological fusion at an average time of 6.8 months post-surgery. Four cases (8.5%) had asymptomatic radiological partial non union at one or more joints but showed clinical union. Five patients (8.3%) had a low energy spiral fracture of the tibia proximal to the locking plate used for TTC fusion. Complete deformity correction with plantigrade foot was achieved in 32 cases (69.5%). Conclusion: Despite a high complication rate associated with Ankle and Hind foot arthrodesis in Diabetic Charcot Neuroarthropathy, an eventually successful fusion can be achieved in two-third patients.

Background: Unstable ankle fractures are common, and majority requires open reduction and internal fixation (ORIF). There is emerging evidence that the rate of malreduction has remained high despite advances in surgical techniques and implants. Malreduced ankle is a prominent cause of post-traumatic ankle arthritis leading to poor patient reported outcome. The aim of this study was to investigate the quality of anatomical reduction and surgical fixation of ankle fractures and the impact of simple education intervention on the quality of reduction of these fractures. Methodology: An audit cycle was completed in two phases; retrospective review (phase 1) of 114 cases operated prior to an education intervention using infographic posters and then a prospective (phase 2) review of 96 consecutive cases operated after the education intervention. Data including age, fracture morphology, time to surgery, and the quality of reduction were assessed. The quality of anatomical reduction was evaluated using radiological parameters described by Pettrone. Paediatric, Weber A, pathological and open fractures were excluded. Education interventions included regional teaching and dissemination of infographic posters. Mann-Whitney U test and Chi-squared test were used to compare continuous and categorical data between phase 1 and 2 respectively. P value < 0.05 was considered significant. Results: Phase one cohort showed malreduced fixation in 25% of cases. Inadequate restoration of fibular length was the most common type of malreduction. After implementation of education intervention, malreduction rate reduced to 9.4% in phase 2 (p ¼ 0.015). There were no significant differences between age, gender, and time to surgery between phase one and two. Conclusion: This study demonstrates that simple education intervention can lead to better understanding of fixation and decrease the rate of malreduction of these fractures. We recommend that using Pettrone's radiological criteria in correction of corresponding anatomy of ankle fracture is a useful tool to avoid malreduction.

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